This is a very fine and important book about a little researched period of psychiatric institutional history. Most of us may be familiar with the figures of the Enlightenment: Pinel and Tuke and later Dix and Beers and so on. But few of us, until Steven Taylor has reminded us, may be quite so informed about the immense contribution that the Conscientious Objectors (COs) of World War II made to the humanitarian reform of the psychiatric system in then USA.

There was something of the order of 12,000 COs in the USA at that time. the majority were young men and women who belonged to what might be called the Peace Churches (branches of the Baptists, Methodists, Mennonites, Quakers), and some were secular pacifists. Many then chose to work in public service, which usually meant menial and low paid jobs, rather than enter the armed services, and about 3,000, assigned through the Civilian Public Service (CPS) system under the Selective Training and Service Act of 1940, volunteered to work in psychiatric hospitals across America, most often as aides in over-crowded and primitive conditions. The COs themselves had suggested this work, seeing it as more socially responsible and productive than lumber camps. However it is unlikely than any of them knew what to expect. What they saw and experienced, and how they reacted to it changed history.

The men and women were sent to camps, as they were termed, and to large psychiatric institutions such as Byberry in Philadelphia (coincidentally founded by Benjamin Rush) where they found themselves, without training or support, placed in charge of locked wards of a hundred or more men who were more often than not naked, untreated, urine stained and smeared with feces, and subject to random beatings, physical abuse and conditions worse than a Dickensian prison. The conditions were brutal and harsh, and both the aides and the inmates had become brutalized. The COs were not just appalled, they were spurred to action.

At first, the reaction was local, but soon the COs and their affiliates both in the church movements and the social justice organizations, began to develop a coordinated response. The hospital authorities and administration were then trapped in an awkward position. The COs tended to be more hard working and reliable than the pre-war staff who were often men with no great record of work attendance, or sobriety. The hiring criteria were low and the pay reflected that. The COs, however, would often volunteer outside of work time, put in extra effort, were reliable and dutiful, but were both critical and vocal. They were driven by a moral imperative and had outside connections that made their protests more public.

Over a period of a few years they became part of a movement that mobilized reform. There were other exposés in the press, most notably by Albert Deutsch who published a series of damning articles in PM, and particularly the photojournalism of Life which published a shocking set of photographs taken at Byberry in 1945. There was also the publicity attached to Mary Jane Ward's novel, The Snake Pit (and the subsequent film) and even the support leant by Eleanor Roosevelt in her own newspaper column, My Day. The COs were able to raise the profile of the aides and not only managed to have the name changed from 'attendant' but introduced training, certification and even awards for the very best.

However, as the reform movement became more organized it also became more political and to some extent splintered. After the war had ended many of the most involved COs continued their work and this led to the formation of the National Mental Health Foundation, which saw as its mandate to advocate for patient rights and to give them a voice. However, this momentum was difficult to sustain and the NMHF eventually merged with other similarly motivated but still rival organizations, the National Committee for Mental Hygiene (the successor to Clifford Beer's original movement from early in the century) and the emerging American Psychiatric Foundation to form the National Association for Mental Health, which in turn became the National Mental Health Association. In the course of these organizational restructures much of the patient-centered focus was lost, and the reform movement took another tack.

It is said that perhaps the most tangible outcome of the CPS mental hospital program was the establishment of the Mennonite Mental Health Services. This was concerned with direct care and eventually consisted of both hospitals and community services across the USA and laid much of the template of the later reforms. That alone is a major achievement, but as the book makes clear the legacy is still being realized.

Although the post-war history is complicated, and to some extent outside the main thrust of the work, Taylor has produced a book of great scholarship and compassion. It is detailed and holds together a complicated narrative while examining in depth the experiences, motivations and effects of the COs; and also the reactions within the psychiatric establishment some of which deserve great credit and some of which should rightly make us flinch. It should be recognized that the later history is a separate project, and that the attention he draws to the impact of the COs on the mental health system was profound, important and long-lasting. Professor Taylor should be congratulated on one of the best psychiatric histories of recent years. It should be recommended to all those with an interest in the subject, and also to those who have not really thought about it before. As Taylor concludes, all acts of conscience are in some respect deserving of praise and honorable, and those who commit them should be remembered and praised.

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